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Viso v. Federated – Plaintiff Failed To Provide Proof Of Disability

This case involves Viso, who filed a disability claim with Federated Insurance due to congenital hearing loss. The policy provided for up to 60 months of disability insurance benefits should Viso become disabled before age 65. The policy included the following definitions:

“Total Disability: You’ll be considered totally disabled if because of sickness or injury:

  1. you are under the regular and personal care of a physician; and
  2. you are unable to perform the substantial and material duties of your regular occupation.

Partial Disability: You’ll be considered partially disabled if because of sickness or injury:

  1. you are under the regular and personal care of a physician; and
  2. you can perform some, but not all, major duties of your regular occupation; and
  3. you are able to work at your regular occupation no more than 20 hours per week.”

Viso’s physician, Dr. Steven Dear, partially completed his Statement of Disability, but it did not assess his ability to work. Federated denied Viso’s claim on multiple grounds, including the absence of a physician’s certification of Viso’s inability to work.

Viso received a denial letter from Federated Insurance. After quoting the policy language and listing the information Federated had considered in its review, it stated:

“In summary, your physician did not certify your inability to work; therefore, you do not satisfy the requirements for Total or Partial Disability. Also, we did not receive the Proof of Loss as outlined by your policy, since you do not satisfy the requirements as indicated, no disability payments are payable.”

However, Viso did not submit any additional information. Viso then filed a lawsuit for breach of contract, bad faith, and intentional infliction of emotional distress in the United States District Court for the Northern District of California.

Federated Insurance’s Arguments:

  1. Federated contended that Viso failed to show he was under the “regular and personal care of a physician.”
  2. Federated argued that Viso could not show he could not perform the “substantial and material duties of his regular occupation.”
  3. Federated questioned whether Viso even had a “regular occupation” when he made the claim.
  4. Federated believed the claim was untimely.

Viso’s Arguments:

  1. Viso argued that he was under the “regular and personal care of a physician” to the extent medically necessary given his condition.
  2. Viso contended that he could not perform the “substantial and material duties” of his regular occupation as described when the policy was issued.
  3. Viso asserted that his claim was timely and that he was not required to have been in a “regular occupation” immediately before making the claim.

The Court’s Decision:

The court found genuine issues of material fact on several of Federated’s contentions. However, the court agreed with Federated that Viso failed to provide a physician’s certification of his inability to work, a requirement under the policy. This certification was critical, and the court found that Viso’s failure to provide this made him ineligible for benefits.

“The final reason that Federated contends summary judgment is warranted, and the basis on which his claim was actually denied, has merit. As the insured, Viso had the initial burden of establishing that his claim was within the scope of coverage. As noted above, Viso has never provided a physician’s certification of his disability, even in these proceedings. While it is apparent that Viso suffers from substantial hearing loss and it may be obvious that it would present at least some obstacles for him in the workplace, he has never shown that he has a disability that would prevent him from carrying out all or some of the substantial and material duties of his regular occupation, even with accommodation. Viso’s own testimony as to the difficulties he experienced on the job may be sufficient to create a factual issue as to whether he was in fact disabled, but it does not create a triable issue as to whether he sufficiently proved he was disabled when he submitted his claim to Federated.”

In Conclusion

The court granted Federated’s motion for summary judgment, determining that while there were factual disputes on some issues, Viso failed to provide the necessary medical certification to prove his disability claim. As a result, Viso’s claims for breach of contract, bad faith, and intentional infliction of emotional distress failed.

Disclaimer: This case was not handled by long-term disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.

Here is a PDF copy of the decision: Viso v. Federated Life Insurance Company